Professional Documents
Culture Documents
DRC PHR Medical-Certificate Feb-2015
DRC PHR Medical-Certificate Feb-2015
Confidential Document
Today’s Date 21/03/2020 Time 12: 00 Location of medical exam- Fooper Muncipal Hospital
A. PATIENT INFORMATION
1. Last name- Suri 2. father-name- Ratan 3. First name- Tara
b. finger(s)
c. foreign body
2. Penetration of anus with: Yes No Attempted Not known Comments:
a. penis
b. finger(s)
c. foreign body
3. Oral contact with genitalia: Yes No Attempted Not known Comments:
a. supect to patient
c. patient to suspect
a. suspect to patient
c. patient to suspect
a. suspect to patient
c. patient to suspect
e. patient to self
REMEMBER TO: COLLECT EVIDENCE (wet and dry secretions, stains, clothing and foreign materials from the patient’s body);
USE RAPE KIT (when available) AND CHAIN OF CUSTODY FORMS; and TAKE PHOTOGRAPHS
J. TREATMENT / PLAN
1. Post-exposure Prophylaxis (PEP) Yes Non Comments:
a. PEP
b. Pain medicine
c. Emergency contraception
d. Other
K. EVALUATION FINDINGS
1. History of event:
2. Behavioral observations:
3. Physical findings:
4. Laboratory tests:
L. EVALUATION CONCLUSIONS
1. CONSISTENT with
HIGHLY CONSISTENT with
The medical evaluation findings are: SEXUAL assault.
(choose only one option) DIAGNOSTIC of
M. CLINICIAN OATH
I have provided informed consent to the patient for the evaluation, photographs, and transfer of affidavit to the legal system or law enforcement.
Yes No
I hereby solemnly swear that the information provided in this form is true and complete to the best of my knowledge and belief.
Name of clinician Dr. Sachin Malhotra
Signature of clinician Sachin
Date 21/ 03/2020